| NPI | 1497188247 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223X0400X Dentist Orthodontics and Dentofacial Orthopedics (Licence: WA DE60660201) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: CA 62802) |
| Enumeration Date | 2013-08-15 |
| Last Update Date | 2019-07-22 |